MedicaidCoverageHigh impact
22-469 Bill Physician-Administered Drugs as a Medical Benefit for Medi-Cal Members
Health Net·CA · Oncology, OB-GYN, Family Medicine +1 more·Prior Authorization
We identified it
Jun 20, 2026
Summary
Physician-administered drugs (PADs) including chemotherapy, anti-rejection medications, and long-acting contraceptives must be billed as medical benefits on medical claims for Medi-Cal members, not through Medi-Cal Rx pharmacy benefits. Only rare exceptions with approved pharmacy prior authorization allow PADs to be billed through Medi-Cal Rx.
Action Required
Immediately: Billing team must ensure all physician-administered drugs (chemotherapy, anti-rejection medications, long-acting contraceptives) are billed on medical claims to fee-for-service fiscal intermediary or Health Net, not to Medi-Cal Rx. Update billing system rules to route PAD claims to medical benefits. Do not direct Medi-Cal members to pharmacies for PADs unless there is an approved pharmacy prior authorization exception. Claims billed incorrectly to Medi-Cal Rx will cause payment delays.